AV shunt (less common)
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Transcript AV shunt (less common)
ACUTE RENAL FAILURE
CHRONIC RENAL FAILURE
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What does the kidney do in terms of?
wastes and water balance?
Acid base balance?
Controlling BP?
Controlling anemia?
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Kidneys
no longer function properly
Kidneys unable to excrete waste
kidneys cannot concentrate urine
Kidneys cannot conserve electrolytes
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GLOMERULAR FILTRATION:glucose, amino acids,
creatinine, urea, phosphates, uric acid
GLOMERULAR REABSORPTION:bicarbonate,
phosphates, sulfates, 65% of Na and water, glucose, K,
amino acids, H ions, urea
GLORMERULAR SECRETION: hydrogen and
potassium, remove acids (hydrogen) to maintain
appropriate acid base balance, potassium, urea
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u/a: negative for glucose, protein, blood,
leukocytes, nitrites, ketones
Specific gravity: measures concentration of
the urine; normal values: 1.010-1.025
Urine osmolality: normal 300-900 mOsm/
kg/24
Serum creatinine: 0.6-1.2mg/dl
BUN: 7-18mg/dl
BUN to creatinine ratio: about 10:1
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OLIGURIA:
POLYURIA:
ANURIA:
NORMAL
URINARY OUTPUT:
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PRERENAL
or factors external to the kidney
which interferes with renal perfusion (55%
cases of ARF)
INTRARENAL: conditions
that cause direct
damage to renal tissue (35-40% cases of ARF)
POSTRENAL: mechanical
obstruction in the
urinary tract (5% cases of ARF)
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Multiple
problems may exist at same
time
AGING
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Retention
of metabolic wastes
Imbalance of fluid and electrolytes
Alterations of sensorium
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Oliguria
Diuresis
Recovery
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Urinary changes
Fluid volume excess
Metabolic acidosis
Sodium balance
Potassium excretion
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Hematologic
disorders
Calcium deficit and phosphate excess
Waste product accumulation
Neurologic disorders
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Gradual increase of urine output as a result
of osmotic diuresis
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Do
all patients recover?
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Restore
renal function
Identify cause
Eliminate cause
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How
do we assess fluid excess?
How can we control fluid intake?
What physical assessments would be
done?
What would you expect to see?
What laboratory tests would be used to
assess client status?
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Elevated serum phosphate:
Hypocalcemia:
Hypermagnesemia:
Hypovolemia:
Fluid retention: diuretics:
Hypertension:
Metabolic acidosis:
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Regular
insulin IV
Sodium bicarbonate
Calcium gluconate IV
Dialysis
Kayexalate
Dietary restriction
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dietary
protein
calories
K and phosphorus
Na
Fe
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Progressive
deterioration in renal
function resulting in fatal uremia (excess
of urea and other nitrogenous wastes in
the blood)
Irreversible destruction of nephrons
Called ESRD (end stage renal disease)
Dialysis or transplant
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Azotemia: collection
of nitrogenous
wastes in blood
Uremia: azotemia
Uremic syndrome: systemic clinical and
laboratory manifestations of ESRD
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Metabolic Disturbances:
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elevated BUN,
creatinine,
hyponatremia,
hyperkalemia,
metabolic acidosis,
hypocalcemia,
hyperphosphatemia
Integumentary Disturbances: pruritus,dry,hair brittle,
nails thin, UREMIC FROST: white/yellow crystals of
urate on skin
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Gastrointestinal
Disturbances: Anorexia, N&V,
metallic taste in mouth, breath smells like
ammonia, stomatitis, ulcers/GI bleeding,
constipation
Neurological Distrubances: uremic
encephalopathy progresses to seizures & coma
CHF: from increased workload on heart from
anemia, hypertension and fluid overload
Uremic pericarditis: pericardium becomes
inflammed from toxins
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Respiratory:
• breath smells like urine: uremic fetor or uremic
halitosis
• Metabolic acidosis: see tachypnea (increased
rate) and hyperpnea (increased depth) indicates
worsening metabolic acidosis
See Kussmaul respirations extreme hyperventilation
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FOR ANEMIA:
FOR HYPOCALCEMIA
FOR FLUID RETENTION AND HYPERTENSION
FOR SKIN ITCHING
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calorie
protein
Na
K
calcium
Phosphorus
Magnesium
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Diffusion of solute molecules through a semipermeable membrane passing from the side of higher
concentration to that of lower concentration
Fluids passing through the semi-permeable membrane
via osmosis
Renal Failure pt has dialysis to remove waste products
and to maintain life until kidney function can be
restored
Dialysis indicated for high levels of K and fluid
overload
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Sterile
dialyzing fluid is introduced into
the peritoneal cavity
Peritoneum is an inert semipermeable
membrane
The dialyzing solution promotes osmosis
leading to diuresis
Urea and creatinine are removed
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Baseline VS and wgt
Assess for fluid overload
Maintain highly accurate inflow and outflow
records
When PD starts the outflow may be bloody or
blood tinged
This clears within a week/two
Effluent should be clear and light yellow
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Drainage bag is lower than the client’s
abdomen to enhance gravity drainage
Avoid kinking or twisting, ensure clamps
are open
Reposition client to stimulate inflow or
outflow
Sitting/standing/coughing: increases
intraabdominal pressure
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Respiratory difficulties
Hypotension
Infection:
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peritonitis: see cloudy or opaque dialysate outflow (effluent),
fever, abdominal tenderness, pain, malaise, N&V
Hypo-albuminemia
Bowel perforation:
Bladder perforation:
Catheter may get clogged
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Fibrin
Clot formation
Milking the tubing
Xray
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Dialysate
leakage
See with obese, diabetic, older clients,
those on long term steroids
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Process
by which the uremic toxins and
accumulated waste products are
removed from the blood
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A
synthetic semi-permeable membrane
replaces the renal glomeruli and tubules
and acts as a filter for the impaired
kidneys
Must have 3 times/week for 4 hours per
treatment for rest of life
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AV
shunt (less common): external silastic
tubing placed in an adjacent artery and vein
AV Fistula: internal access using pts own
vessels (artery and vein)
AV Graft: internal access using a foreign
material
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BLEEDING
INFECTION
CLOTTING
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Assess for disequilibrium reaction
CAUSE:
due to rapid decrease in fluid volume and BUN levels
Change in urea levels can cause cerebral edema and
increased intracranial pressure
Neurologic complications: HA, N&V, restlessness,
decreased LOC, seizures, coma, death
PREVENTION: starting HD for short periods
with low blood flows
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Vasoactive
drugs which cause
hypotension are held until after treatment
CHECK WITH PHYSICIANABOUT WHICH
DRUGS TO BE HELD
Know pt’s BP pre-dialysis
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BP and wgt
Hypotension
Temperature may also be elevated:
If client has a fever
Bleeding risk:
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Involves
transplanting a kidney from a
living donor or human cadaver to a
recipient who has end-stage renal
disease and requires dialysis to live
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major concern is rejection
Drugs given to suppress immunologic
reactions: Imuran, prednisone,
cyclosporin (Cyclosporin A)
Next concern is infection
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TO DETECT REJECTION:
Assess for increased temp, pain or
tenderness over grafted kidney
Assess for decrease in urine output,
edema, sudden wgt gain
Assess for rise in serum creatinine and
BUN values
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